In mild‑to‑moderate atopic dermatitis, is a 1% hydrocortisone cream or ointment the preferred formulation?

Hydrocortisone Ointment is Preferred for Eczema

For mild-to-moderate atopic dermatitis, 1% hydrocortisone ointment is the preferred formulation over cream because ointments provide superior occlusion and enhanced barrier repair, which directly addresses the fundamental pathophysiology of eczema—impaired skin barrier function. 1

Rationale for Ointment Preference

Barrier Function and Efficacy

• Ointments create an occlusive lipid film that retards evaporative water loss from the epidermis, which is critical since atopic dermatitis patients inherently have compromised barrier function 1
• The enhanced occlusion with ointment formulations increases corticosteroid penetration and effectiveness compared to cream bases 1
• Ointments are specifically recommended for dry skin presentations, which characterize most eczema cases 2

Clinical Application Algorithm

For acute/weeping eczema:

• Use cream formulation initially when significant exudation is present 2
• Transition to ointment once acute weeping resolves 2

For chronic/dry eczema (most common):

• Start directly with 1% hydrocortisone ointment 1
• Apply twice daily for maximum 2-3 weeks during flares 2, 3
• After the first day of acute treatment, once-daily application may be sufficient based on pharmacokinetic data showing plasma cortisol peaks within 24 hours 3

Treatment Protocol

Proper Application Sequence

• Apply hydrocortisone ointment first directly to affected skin 2
• Allow several minutes for absorption 2
• Follow with emollient application over the treated areas 2
• Never reverse this order—barrier creams block medication penetration if applied first 2

Duration and Frequency

• Limit to twice daily application maximum (once daily may suffice after day 1) 1, 3
• Restrict use to 2-3 weeks maximum per treatment course 2
• Even mild-potency hydrocortisone causes measurable epidermal thinning after just 2 weeks of continuous use 4

Critical Maintenance Strategy

Long-Term Management

• Emollients (200-400g per week) must become the cornerstone of ongoing therapy, not the corticosteroid 2
• Continue emollient ointments twice daily indefinitely, even when skin appears clear 2
• Reserve hydrocortisone ointment for intermittent flare management only (3-7 days per episode) 2

Common Pitfall to Avoid

• The most frequent error is stopping hydrocortisone without establishing robust emollient maintenance, which leads to rapid recurrence since the underlying barrier dysfunction was never addressed 2
• Patients need 100g of emollient for trunk or both legs per 2-week period for adequate coverage 2

When to Escalate Beyond 1% Hydrocortisone

• If no improvement after 2 weeks of twice-daily 1% hydrocortisone ointment, escalate to moderate-potency topical steroid (e.g., triamcinolone 0.1%) rather than continuing ineffective therapy 2
• For moderate-to-severe disease, 1% hydrocortisone may be insufficient from the outset—consider higher potency agents initially 5, 6

Safety Considerations

• 1% hydrocortisone ointment is adequate for mild-to-moderate disease and does not cause systemic side effects unless used extravagantly 1
• Transient epidermal thinning occurs but reverses within 4 weeks after discontinuation 4
• The main risk with any potency is pituitary-adrenal axis suppression with prolonged use, particularly concerning for growth interference in children 1